At the beginning of the fourth stage of labor the nurse assess what four things? (Select four correct answers).
Fundal tone
Lochia
Transcutaneous bilirubin
Engorgement
Vital Signs
Bladder distension
Correct Answer : A,B,E,F
A. Fundal tone assessment helps detect uterine atony.
B. Lochia assessment monitors postpartum bleeding.
C. Transcutaneous bilirubin is not assessed in the immediate postpartum period.
D. Engorgement relates to breastfeeding and is not a priority in the fourth stage.
E. Vital signs are crucial to monitor for hemorrhage or shock.
F. Bladder distension can affect uterine contraction and bleeding.
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Related Questions
Correct Answer is C
Explanation
A. To identify abnormal fetal cells: This is typically the purpose of amniocentesis earlier in pregnancy to check for genetic disorders, not at 34 weeks.
B. To detect metabolic disorders: Metabolic disorders are usually identified through newborn screening after birth rather than through late pregnancy amniocentesis.
C. To determine fetal lung maturity: At 34 weeks gestation, determining fetal lung maturity is critical, especially in cases of preeclampsia, as early delivery might be necessary.
D. To identify the sex of the fetus: The sex of the fetus is usually determined earlier in pregnancy if necessary, not at 34 weeks, and it is not the primary purpose in this context.
Correct Answer is C
Explanation
A. Both placenta abruptio and placenta previa can involve bright red bleeding, though their underlying causes and presentations differ. Therefore, this statement is not entirely accurate.
B. Placenta previa is usually visible on ultrasound, while placenta abruptio is diagnosed based on clinical signs (bleeding, pain) and ultrasound when available.
C. Abruptio placenta can cause severe abdominal pain due to the separation of the placenta from the uterine wall. This is a key distinguishing feature from placenta previa, which typically does not cause pain.
D. Placenta previa is not treated by induction of labor unless it is term and the placenta is low-lying. It is typically managed by planned cesarean delivery.
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